adventures in public health and human rights

Menu

Aid donor 1: So I thought we should meet to talk about how better to coordinate our [thing] distribution programme.

Aid donor 2: yes, thanks for the initiative, we’ve heard from the government that they would like us to rationalise our efforts – it’s a huge country but the way we’re working right now, most of the [things] are concentrated in 2 or 3 districts, and…

Aid donor 1: True, but those are also the districts where the highest number of people needing [things] live, and we’ve decided that they should be our [thing] focus districts for our programme going forward. At least for the next year.

Government: Can I…

Aid donor 2: OK, so we’re fine with that, we can just move out of your [thing] focus districts and go to other districts.

Aid donor 2’s number 2: Kind of, but our [thing] distributors are going to struggle with that because they’ve built up all their [thing] distribution networks in those districts, they’ve influenced [thing] consumption norms, they no they can hit their targets because there are high levels of [thing] demand there, they’ve…

Aid donor 1: OK so let’s have a transition plan so that you can hand over those districts…

Aid donor 1’s number 2: I’m not sure we want them to hand them over entirely…

Aid donor 1: Really?

Aid donor 1’s number 2: The thing is, in some of those districts we are promoting the [things], changing attitudes to [things], and building the capacity of [thing] distributors, but we aren’t actually funding the [things]. Aid donor 2 is paying for the [things].

Government: There’s also some work there by Aid donors 3 and 4, and in a couple of districts we are using government money to…

Aid donor 2: So will you take over the funding of the [things] in your districts, Aid donor 1?

Aid donor 1: Yes of course! Mostly. I mean, some of them – but we’re talking a LOT of [things]. We might need you to keep on paying for some of them. Quite a lot of them, even.

Government: What we would like is for each Aid donor to fund its own [things] in its own districts (they’re actually not really *your* districts because it’s not your country, but whatever…).

Aid donor 1: Yes, Government, absolutely, that’s what we want and what we will do. But it’s also important to be flexible.

Aid donor 2: So Aid donor 1, you are going to take over some of our [thing] consumers? Then you get all the people already consuming [things] and we have to build up our [thing] consumer numbers from scratch again.

Aid donor 1: Well actually they are our [thing] consumers already.

Aid donor 1’s number 2: Our definition of a [thing] consumer includes anyone who got a [thing] in our districts even if we didn’t actually pay for the [thing].

Government: If you add all of your [thing] consumers together, that’s well over a hundred thousand [thing] consumers – great impact!

Aid donor 2’s number 2: But you can’t add those numbers together. In some cases they’re the same [things]. They’re the same [thing]consumers. That would be double counting.

Aid donor 1: That’s our definition and that’s what we have to report. We want to know who our [thing] consumers are. They are ours. OURS.

If you don’t have time to read ODI’s 50 odd page report on Adapting development (part of the “doing development differently” movement) then I can recommend at least looking at Duncan Green’s good summary here. It is full of good examples and will probably have most aid people nodding (once they get over cringing at the concept that development is something that international donors and NGOs “do”).

I also find it slightly frustrating because although these insights have been gaining currency for a few years now I’m not optimistic that aid agencies are really taking them on board (something which I keep going on about: blah; blah; blah).

My pessimism stems largely from knowing what most aid agencies are like but I also feel like the recommendations in the report don’t exactly rock the boat:

• Being adaptive and entrepreneurial.

• Supporting change that reflects local realities and is locally led.

• Aiding development that is politically smart and locally led.

And for monitoring the extent to which programmes adopt these approaches:

• Measures of the extent to which issues have local salience or relevance, and whether processes give priority to local leadership and capacity.

• Evidence of adaptation to context.

• Evidence of learning in action.

• Measures of innovation and entrepreneurial action.

These are fine but they just look a bit too much like things that most aid agencies claim they are doing anyway – you’d be hard pushed to find an agency that does not believe it is living these values already. And as for the monitoring recommendations I’m envisioning swathes of new toolkits and indicators that “promising local change agents” are going to have to spend even more time reporting on and telling donors about (and consequently having far less time to promisingly agent local change). And given how much we love a shortcut, it’s not a stretch to imagine that “asking simple questions about the extent to which users and local networks and organisations are involved in issue selection, design and implementation” could very easily turn into mandating the precise structure and composition of the multi-sectoral local coordination committee. E.g.

In short, while I think a lot of the thinking in this report is going in the right direction, it feels to me like it is a version of progress and development that is all about aid donors and (smart) international aid people. And while I do think we can contribute a lot, I don’t think it should be left up to us.

Aid donors have, for a long time, asked recipient governments (or agencies) to come up with counterpart funding, or in layperson’s terms, to pay a share of the cost of a programme. It is a slightly complex issue, given that money is fungible – for instance, if the UK’s DFID were to offer a country £9 million for an HIV treatment programme on the condition that the country would stump up a further £1 million, that £1 million has to come from somewhere. We’d like to imagine it is going to be taken off the defence budget but the chances are it will come from somewhere else in the health budget. Either way, it means the donor is using their financial clout to influence how the recipient government’s spending decisions.

There’s another conundrum. Often a donor will pay out on a co-funded programme on the basis that the recipient government has given a guarantee or commitment that it will pay its share. But what if that share never comes – either due to bad will, or because there were other, more pressing claims on that pot of money? Should donors “trust” commitments from recipient governments? If they’ve got reason to believe that the co-payment might not be forthcoming, should they decide to spend the money in another country, where the government is going to co-pay? Do they take the risk and fund the programme with an unreliable co-funding commitment? Or do they decide to scrap the co-payment condition and give the funds anyway, so as to avoid the embarrassment and reputational risk of the co-funding never coming through?

The last scenario seems to defeat the whole purpose of co-payment policies, but it probably means more lives will be saved (which is, after all the purpose of aid). But what is worrying about it, is that it means the donor is taking responsibility for the possible/probable default of the country. Whose responsibility is it?

Two leading AIDS researchers and activists – Chris Beyrer and Chris Collins sound a loud warning in the Lancet Global Health about the risks of a “too rapid” toward increased country ownership of the response to HIV and AIDS. While they underline that country ownership is “fundamental to long-term progress in global health”, they argue that many countries are not ready. Theirs is quite a different take from the one I put forward on this blog last week, and I feel they have fallen into the simplistic trap of seeing country ownership as being about governments.

Much of their concern centres around the funding gap – and they are right to say that many countries are many years away from being able to finance their own AIDS responses (the same point could be made about health or welfare programmes in general). But country ownership is not just about where the money comes from – indeed the fact that country ownership is a core principle of aid effectiveness suggests that it has very little to do with the withdrawal of aid financing. This is not to say that the source of funding does not have an impact on ownership. As I argued in my post, even if a country “can’t support its health care needs right now, what it can do is start to claim a bigger stake in the funding and governance of its health”. Country level campaigns for increased government, private sector, and community spending on health are about countries claiming a bigger stake in their HIV programmes, and building the social contract at a national level.

Beyrer and Collins rightly point to the fact that in many countries, health systems still have limited capacity to implement and monitor programmes. But ten years into the scale up of one of the largest global health ventures – the response to HIV and AIDS – surely this should be the signal for more effort in promoting country ownership in implementation. Promoting country ownership in the context of aid funding means doing much better in terms of building those local systems, and enabling the development of policies at country level. It means working with those who already own their national responses: governments, ministries of health, and NGOs. And it means using operating procedures that are suited to national systems. Another emerging challenge to country ownership is the consequence of donors’ increased focus on results and accountability. The focus itself is entirely appropriate. However, the processes that are being put in place to enable this focus are often premised on an international system of monitoring and auditing. Country ownership means that these functions too should reside at national level.

In many countries there remain considerable barriers to certain types of programming – for instance with key populations. But while Beyrer and Collins are right to point out that most of the programming with these groups is externally funding, these programmes remain underfunded in most countries. The reason that less controversial programmes – such as for antiretroviral treatment and prevention of mother to child transmission – have scaled up so successfully is precisely because governments, ministries of health and NGOs at country level have readily embraced them. We will not see a satisfactory scale up of key population programming simply by mandating from global level that it must happen, or by approaching the issue primarily from the perspective of a humanitarian response. Decision makers, service providers, activists on the ground have to back it. Country ownership doesn’t mean abandoning people in need, it means recognising and working with these processes so that these needs can be met in a more meaningful, sustainable way.